Time To Get Tough On Heart Disease: What Does That Mean For Diet?

(Part one of a two-part feature on heart disease and diet.)

We all know it's important to eat a heart-healthy diet, but exactly what does that mean? If you're confused. you're not alone. Diet advice has changed over the years and diet dogma from the government was recently revised yet again. Still, some truisms remain. In this two-part series, EN looks at the foods, supplements and eating patterns that show the greatest promise for keeping your heart healthy.

Tougher Guidelines Issued. Last month, the National Cholesterol Education Program (NCEP) released new recommendations to help prevent and treat heart disease. The primary focus remains on lowering low-density lipoprotein ("bad" LDL) cholesterol levels, because high levels increase the risk of heart disease.

A low blood level of high-density lipoprotein ("good" HDL) cholesterol has long been considered a risk factor for heart disease, but the guidelines now cite as risky any value under 40, instead of under 35. The new guidelines also urge more aggressive treatment of high triglyceride levels and metabolic syndrome. (Also known as Syndrome X, metabolic syndrome is marked by a clustering of factors, including insulin resistance, excessive abdominal fat, high blood pressure, elevated triglyceride levels and low HDL's. The combination of factors dramatically increase the risk of heart disease.)

The stricter guidelines will qualify more people for medication, a controversial move that made headlines. But the group also issued new dietary guidelines to help lower high LDL's. Being on medication does not negate the need for diet; the two go hand in hand in decreasing the risk of first-time and repeat heart attacks and strokes.

Saturated Fat: Still a Villain. One of the major changes in the new recommendations is the liberalization of total fat intake, allowing up to 35% of calories as fat, provided saturated and trans fats are kept low. People at risk for heart disease are urged to reduce saturated fat to less than 7% of calories and to cut dietary cholesterol to less than 200 milligrams a day to reduce LDL-cholesterol even more, says Neil Stone, M.D., professor of cardiology at Northwestern University.

Although statin drugs prescribed to lower blood cholesterol do the job, they affect only the cholesterol your body makes, not what you take in. By also slashing saturated fat, you further lower blood cholesterol, while keeping dietary cholesterol down as well, since the two are often paired in foods.

To keep saturated fat within a healthy range, choose fat-free or 1% fat versions of dairy products (milk, cheese, ice cream, sour cream), lean meats, fish and skinless poultry, and keep the mainstay of your diet focused on whole grains, fruits and vegetables. Go easy on liver, other organ meats and egg yolks--foods in which cholesterol is high even though saturated fat is not--though up to an egg a day may be fine for many people.

Trans Fats: Double Trouble. Research shows that trans fatty acids (unsaturated fats that have been chemically altered by hydrogenation) increase LDL's while decreasing HDL's, a double whammy for the heart. Adding to the burgeoning evidence against trans fats is a recently published study of elderly Dutch men who were free from heart disease at the beginning of a 10-year study. Those with the highest intake of trans fats were most likely to develop heart disease by the end of the study.

Although there is no official recommended limit for trans in the diet, many experts suggest that trans and saturated fats combined should not exceed 7% of calories, especially for people at high risk for heart disease.

To keep trans intake low, choose soft margarines (liquid or tub) instead of stick margarine or butter, opting for a brand that is low in saturated fat and trans-free (look for "0 trans" on the label). Limit the cookies, pastries, crackers and fast-food fries you eat; check ingredient labels for hydrogenated fats.

Mono's (and Other Fats): Much Misunderstood. While monounsaturated fats have been in the spotlight lately as the "fat of choice," the pendulum is swinging back to a diet moderate in polyunsaturated fats (up to 10% of calories) along with more mono's (up to 20%). But the increased mono fat allowance shouldn't be taken as a license to drizzle olive oil over everything. Keeping your body at a reasonable weight is a priority, and increasing fat intake would risk weight gain.

Still, research shows that a diet higher in fat--if mainly mono's and poly's--can help raise HDL's and reduce triglycerides in people with Syndrome X, as can reducing weight and increasing physical activity. Additionally, curb carbohydrates to 45% of calories, choosing complex carbs, like whole grains, fruit, vegetables, beans and peas.

Soluble Fiber, Sterols, Stanols: Go Get `Em. If LDL-cholesterol levels don't drop after six weeks of a diet low in saturated fat and cholesterol, the NCEP suggests increasing soluble fiber to 10 to 25 grams a day (total fiber intake should be 20 to 35 grams a day). Soluble fiber, in particular, helps lower blood cholesterol levels, by binding with cholesterol so it is excreted.

Good sources of soluble fiber include oats, fruit (especially citrus fruits, pears, apples, berries, prunes and apricots), vegetables (particularly Brussels sprouts, sweet potatoes, cabbage and carrots) and dried beans and peas. Most experts, however, don't recommend fiber supplements.

The new guidelines also recommend plant sterols and stanols, the active ingredients in cholesterol-lowering margarines like Take Control and Benecol. By blocking the absorption of cholesterol from the intestines, they can lower LDL's an additional 10% beyond the recommended diet. "However," cautions Stone, "these products aren't necessary if cholesterol levels are normal."

EN's Bottom Line. Despite the new push for greater use of cholesterol-lowering drugs to decrease the risk of heart disease, the focus still includes diet: Reduce saturated fats, trans fats and dietary cholesterol. Boost soluble fiber and plant sterols/stanols. If people followed this advice, says Dennis Sprecher, M.D., of the Cleveland Clinic, we would see a dramatic drop in heart disease.

Next month: EN looks at substances like nuts, garlic, soy, vitamin E, B vitamins and alcohol and whether they can help promote a healthy heart.

New Blood Level Ranges (milligrams per deciliter)
Total Cholesterol

<200 Desirable

200-239 Borderline high

Is greater than or equal to 240 High

LDL Cholesterol

<100 Optimal

100-129 Near or above

130-159 Borderline high

160-189 High

Is greater than or equal to 190 Very high

HDL Cholesterol

<40 Undesirable

Is greater than or equal to 60 Desirable


<150 Normal

150-199 Borderline high

200-499 High

Is greater than or equal to 500 Very high
Source: NCEP/ATPIII Report, 2001


By Kerry Neville, M.S., R.D.

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